Classification of maxillodental-facial abnormalities and deformities

Classification of maxillodental-facial abnormalities and deformities.

 

There exist a lot of anomalies and deformations with similar clinical presentation. In this connection there have been offered numerous different classifications which allow systematizing various types of dentognathic anomalies. Anomalies systematiza-tion enables to choose a correct approach to their understanding, study etiopathoge-netic factors of their origination, put a diagnosis and plan treatment.

All the classifications of dentognathic anomalies are mainly built on the registra­tion of morphologic deviations, functional disorders, etiologic factors or their combi­nation.

The most wide-spread are the classifications built on the basis of morphologic changes. They are grounded on the immovable junction of the facial skeleton, exclud­ing the lower jaw, with other cranial bones. Thus, according to scientists, the facial skeleton does not undergo the harmful influence of internal and external factors and is not exposed to such changes as the dentognathic apparatus is exposed to.

The first morphologic classification, based on the principle of dental arches cor­relation on the whole, was offered by E. Angle in 1889. The classification is ground­ed on the mesiodistal correlation of the 1^st permanent molars of both jaws, which are defined by the author with the term “occlusion key”. Angle considered that the lo­calization of the, upper 6^th tooth always corresponds to the localization of the crista zygomatica thanks to its eruption in this place only. The author named the 6^th tooth “punctum fixum” (the fixed point). The permanent localization of the 6^th tooth, ac­cording to the scientist, is determined, first of all, by the immovable junction of the upper jaw with the cranial base, and secondly, by the fact that it always comes out behind the 2^nd temporary molar. Therefore all atypical correlations of permanent molars arise only at the expense of the irregular position of the lower jaw.

Angle divided occlusion anomalies into three classes.

The 1^st class — “occlusion key” is not violated: the mesial buccal tubercle of the 1^st upper permanent molar is located in the intertubercular sulcus of the lower 1^st permanent molar. Thus, the pathology is only localized in front of the 1^st molars and concerns either teeth arrangement or alveolar process and jaws bodies development (Fig. 88, a).

The 2^nd class is characterised by the distal localization of the lower 1^st permanent molar. At such correlation the mesial buccal tubercle of the upper 1^st permanent mo­lar is in front of the intertubercular sulcus of the lower 1^st permanent molar. Either

 

ig. 88. Occlusion anomalies according to Angle:

a — Angle’s 1^st class; b — Angle’s 2″d class, 1^st subclass; c — Angle’s 2^nd class, 2^nd subclass; d — Angle’s 3^rd class

the contact is defined by similar tubercles or the mesial-buccal tubercle of the upper 1^st permanent molar is located between the tubercle of the 2^nd premolar and the me­sial buccal tubercle of the lower 1^s1 permanent molar, which depends on the complex­ity of the deformity. The changes of teeth correlation concern the whole dental arch. The 2^nd class may have two subclasses of the anomaly: the 2^nd class, 1^st subclass — the distal location of the lower jaw, at which the upper frontal teeth are inclined forward and are fanlike allocated, with diastems and diaereses (Fig. 88, b). The 2^nd class, 2^nd subclass — the upper frontal teeth are inclined in the oral direction, deeply covering the lower ones (Fig. 88, c). In both subclasses the distal correlation in lateral areas may be uni- and bilateral.

The 3^rd class is characterized by the mesial position of the lower 1^st permanent molar relative to the similar upper tooth. At such correlation the mesial buccal tu­bercle of the upper 1^st permanent molar is behind the intertubercular sulcus of the lower 1^st permanent molar. The lower frontal teeth cover the upper ones. 3^rd class anomalies also may be uni- and bilateral (Fig. 88, d).

Except for the sagittal occlusion anomalies Angle differentiates seven types of individual teeth anomalies:

1)labial, or buccal occlusion;

2)lingual, or palatine occlusion;

3)medial occlusion;

4)posterior occlusion;

5)torsion occlusion;

6)infraocclusion;

7)supraocclusion.

Angle’s classification was very popular at the end of the 19″¹ century as it some­how ordered the diagnostics of dentognathic anomalies and deformations. This was the first accessible by its simplicity, the only generally accepted occlusion anomalies classification in the world, which is eagerly used by specialists also nowadays.

But in spite of this Angle’s classification has a number of drawbacks. Firstly, the upper 1^st molar does not always have a stable place: at premolars extraction or their adentia the place may change mesially. Besides, the upper jaw may take the front position in the cranium, and then the location of the 1^st molar changes.

Secondly, it is possible to use the classification only when examining transitional dentition and permanent occlusion.

Thirdly, the classification reflects occlusion anomalies only in the sagittal plane, not taking into account vertical or transversal anomalies.

Fourthly, the classification does not take into account functional and esthetic violations.

In 1940 A.Y. Katz offered the functional classification of anomalies, in which he took into account the functional pathology of mastication muscles. The author took the Angle’s molars correlation as the basis of morphologic changes, considering three pos­sible groups of deviations in the development of the dentognathic apparatus, supple­menting each group of anomalies with the functional state of the craniofacial muscles.

The first group includes all the anomalies with the violation of the functional norm only in the region of frontal teeth, at normal correlation of the 1^st permanent molars. Functional pathology arises due to the prevalence of vertical movements of the lower jaw over lateral movements and declares itself by functional insufficiency of all mastication muscles.

The second group by morphologic structure corresponds to the second class by Angle, and from the point of view of function is characterised by the underdevelop-ment of the muscles protruding the lower jaw. At that, the area of functional mastica­tion surfaces of both dental arches considerably decreases, the dissimilarity of the tubercles and sulci of articulating teeth arises.

The third group corresponds to the third Angle’s class, connected to the excessive function of the muscles protruding the lower jaw.

Thus, in Katz’ occlusion anomalies classification there was an attempt to com­bine the morphologic signs of violations with the functional pathology of mastication muscles and the reason for anomalies development.

The main drawback of the classification is the fact that it takes into account oc­clusion anomalies in the sagittal plane only, and from the morphologic point of view has the same drawbacks as Angle’s classification. Theoretic positions were built on empirical conclusions, as then there were no techniques of studying the functions of separate muscles.

L.V. Ilyina-Markosian’s classification (1967) is built taking into consideration the influence of the function of the oral and perioral muscles on the formation and development of the dentognathic apparatus, and also the structural peculiarities of TMJ, which perform lower jaw movements in different directions with the help of the mastication muscles.

L.V. Ilyina-Markosian offered the classification of occlusion anomalies, built on the signs of lower jaw displacement during teeth joining. This distribution is of great practical meaning. All the anomalies were divided into sagittal, vertical, and transver­sal. Instead of the terms “distal” and “mesial” (occlusion) there were offered the terms “posterior” and “anterior” (Table 26).

A.I. Betelman’s classification (1956) divides all the dentognathic anomalies into the anomalies of individual teeth positions and articulation anomalies.

Articulation anomalies are viewed in three directions: sagittal, vertical, and trans­versal, taking into account the functional pathology by A.Y. Katz.

Characterizing pathologic occlusions the author proceeds from morphologic pe­culiarities of orthognathic occlusion. Deviations in the relations in the sagittal, verti­cal, and transversal planes at orthognathia lead to the appearance of pathologic forms of occlusion in the same three directions. Therefore, according to A.I. Betelman, there is a necessity to differentiate three groups of pathologic forms of dental occlu­sion: sagittal, vertical, and transversal occlusion anomalies.

Sagittal occlusion anomalies include deviations from the norm in the mesiodistal correlation of dental arches: distal and mesial occlusions. Posterior occlusion is char­acterised by the distal position of the lower jaw, and also the functional insufficiency of the muscles protruding the lower jaw and the orbicular muscle of mouth. Besides, depending on the degree of jaws development A.I. Betelman singles out four forms of posterior occlusion:

o the 1^st form — inferior micrognathia;

o the 2^nd form — superior macrognathia;

o the 3^rd form — superior macrognathia and inferior micrognathia;

o the 4^th form — maxillary prognathism with constriction in the lateral areas.

At mesial occlusion the lower jaw is located mesially, the protruding muscles are excessively developed, and retractors are insufficiently developed. Mesial occlusion has such forms:

o the 1^s1 — superior micrognathia;

o the 2^nd — inferior macrognathia;

o the 3^rd — superior micrognathia and inferior macrognathia.

Vertical anomalies include cases of deviations from orthognathia, from the point of view of the degree of the upper frontal teeth covering the lower ones. The patho­logy has two forms: deep and open bites.

Deep overbite arises at the underdevelopment of the muscles protruding the lower jaw; open — at the underdevelopment of the muscles lifting the lower jaw, and also the orbicular muscle of mouth.

Table 26. L.V. Ilyina-Markosian’s Classification of Occlusion Anomalies

 

VERTICAL ANOMALIES (are found relative to the horizontal plane)
Deep Overbite				Open Bite
A. Without lower jaw dis­placement		B. With lower jaw displace­ment		A. Without lower jaw displacement	B. With lower jaw displacement
C. Combined forms — the signs of both groups present				C. Combined forms — the signs of both groups present
A		B		A	B
1. General deep overbite (true deep overbite). 2. Frontal deep overbite.		1. Forced deep overbite (with lower jaw displace­ment, unreal).		1. General open bite (true open bite). 2. Frontal open bite. 3. Lateral open bite.	1 . Forced open bite (with lower jaw displacement, unreal).
SAGITTAL ANOMALIES (are found relative to the vertical plane)				TRANSVERSAL ANOMALIES (are found relative to the sagittal plane)
Posterior (distal) occlusion		Anterior (mesial) occlusion		Lateral (cross) occlusion
A. Without lower jaw dis­placement	B. With low­er jaw dis­placement	A. Without lower jaw displacement	B. With lower jaw displacement	A. Without lower jaw displacement	B. With lower jaw displacement
C. Combined forms — the signs of both groups present		C. Combined forms — the signs of both groups present		C. Combined forms — the signs of both groups present
A	1          B	A	B	A	B
1. General posterior oc­clusion (true prognathism). 2. Frontal posterior oc­clusion (fron­tal progna­thism, un­real).	1. Forced posterior oc­clusion (prognathism with lower jaw displace­ment, un­real).	1. General anterior oc­clusion (true progenia). 2. Frontal anterior oc­clusion (fron­tal progenia, unreal).	1. Forced anterior oc­clusion (progenia with lower jaw displace­ment, un­real).	1. General lateral occlusion (true cross occlusion). 2. Frontal lateral occlusion: — right-side; — left-side. 3. Lateral occlu­sion: — right-side; — left-side; — two-sided.	1. Forced lateral occlusion (cross bite with lower jaw displacement, unreal): — right-side; — left-side. 2. Posterior-lat­eral occlusion: — right-side; — left-side. 3. Anterior-lateral occlusion: — right-side; — left-side

Transversal anomalies include two forms of transversal occlusion: the first form — on one side teeth articulate as at orthognathic occlusion, and on the other side — the upper jaw is narrowed and the lower teeth cover the upper ones; the second form — the whole lower jaw is displaced to one side and because of this on one side the palatine surfaces of the upper lateral teeth cover the buccal surfaces of the lower ones, and on the other side — the lingual surfaces of the lower lateral teeth cover the buc­cal surfaces of the upper ones, i.e. the teeth joiot with mastication tubercles but with smooth lateral surfaces.

This state arises as a result of the functional insufficiency of one of protruding muscles, left or right, depending on the side, to which the lower jaw is displaced. The first is named the unilateral transversal occlusion, the second — bilateral.

A.I. Betelman’s classification of individual teeth position anomalies presupposes 9 types of their position:

1)oral position;

2)vestibular position;

3)supraocclusion;

4)infraocclusion;

5)mesial position;

6)distal position;

7)tooth torsion;

8)diastems;

9)crowding.

The advantage of A.I. Betelman’s classification lies in the facilitation of conduct­ing the differential diagnostics in orthodontics. General notions “distal” and “mesial” occlusions, divided into forms, allow clarifying the differential diagnosis. The classi­fication gives not only morphologic but also functional characteristics of deforma­tions.

Drawbacks of the classification lie in insufficient representation of dentognathic anomalies etiology.

V.Y. Kurliandskyi’s classification (1957) is based on the morphologic occlusion changes. The author noted that at the presence of interdependence between the form and function it is sufficient to characterise the type of anomaly on the basis of one of these factors. According to V.Y. Kurliandskyi’s classification dentognathic deforma­tions are divided into:

1)anomalies of form and location of teeth;

2)dental arch anomalies;

3)anomalies of dental arches correlation.

The first and second forms of dentognathic anomalies include dentoalveolar forms, the third — gnathic. Basic forms of anomalies may combine with the anoma­lies of form and position of individual teeth or with the violations in the correlation of separate parts of dental arches.

V.Y. Kurliandskyi’s classification of dentognathic anomalies

1.       Anomalies of the form and position of teeth.

1.1.    Anomalies of the form and size of teeth: macrodontia, microdentia, spinous teeth,
cube-shaped teeth.

1.2.    Anomalies of the position of individual teeth: torsion, displacement in the ves­
tibular or oral direction, displacement in the distal or mesial direction, violation of the
height of tooth crown location in the dentition.

2.       Anomalies of dental arch.

2.1.Disorder of the formation and eruption of teeth: absence of teeth and their germs
(adentia), supplemental teeth formation.

2.2.Teeth retention.

2.3.Derangement of distance between teeth (diastems, diaereses).

2.4.Irregular development of the alveolar process: underdevelopment or excessive
growth.

2.5.Constriction or dilation of dental arch.

2.6.Anomalous position of some teeth

Anomalies of the position of some teeth.
Development anomaly of one or both dental arches creates a certain type of cor­relation between the upper and lower dental arches:

1)excessive development of both jaws;

2)excessive development of the upper jaw;

3)excessive development of the lower jaw;

4)underdevelopment of both jaws;

5)underdevelopment of the upper jaw;

6)underdevelopment of the lower jaw;

7)open bite;

8)deep overbite.

This classification has both advantages (approach to the study of the size and location of separate areas of the dentognathic apparatus) and disadvantages: it does not reflect the anomalies conditioned by the mesiodistal displacement of teeth and dental arches, lower jaw displacement, etiologic factors of dentognathic anomalies development.

D.A. Kalvelis (1957) considers that classification should be based on the mor­phologic changes of teeth, dental arches, and occlusion on the whole taking into account the etiology and value of these derangements for function and esthetics.

Dentognathic anomalies and deformations are classified in the view of work con­venience of a practicing orthodontist and have three groups:

1)anomalies of individual teeth;

2)anomalies of dental arches;

3)anomalies of occlusion.

D.A. Kalvelis’ classification:

/.   Anomalies of individual teeth.

1.       Anomalies of the number of teeth:

—adentia — partial and full anodontia;

—supplemental teeth (hyperdontia).

2.       Anomalies of the size and form of teeth:

–        gigantic teeth;

—acanthoid teeth;

—distorted forms of teeth;

—Hutchinson’s, Fournier’s teeth.

3.       Anomalies of hard tooth tissues structure:

–        hypoplasia of the tooth crown.

4.       Disorder of the process of eruption:
— premature eruption of teeth;

–        delayed eruption of teeth.
//. Anomalies of dental arches.

1.       Derangement of dental arches formation:

1)       Anomalous position of individual teeth:
— labiobuccal eruption of teeth;

—palatine-lingual eruption of teeth;

—mesial eruption of teeth;

—distal eruption of teeth;

 

–   low position (infraocclusion);

–   high position (supraocclusion);

 

—tooth torsion (torsion anomaly);

—teeth transposition;

—dystopia of upper canine teeth.

 

2)Dense position of teeth.

3)Diaereses between teeth (diastems).

2.       Anomalies of the form of dental arches:

—narrowed dental arch;

—saddle-shaped squeezed dental arch;

–        V-shaped dental arch;

—quadrangular dental arch;

—asymmetric dental arch.
///. Anomalies of occlusion.

1 .   Sagittal anomalies of occlusion:

1)prognathism;

2)progenia: false and true.

2.       Transversal anomalies of occlusion:

1)narrowed dental arches;

2)inadequacy of the width of the upper and lower dental arches:

—      disorder of the correlation of lateral teeth on one side (transversal or unilateral
cross bite).

3.       Vertical anomalies of occlusion:

1)       deep overbite:

—covering occlusion;

—combined occlusion with prognathism (roof-shaped);

2)       open bite:

—true occlusion (rachitic);

—traumatic occlusion (caused by bad habits).

The disadvantage of the classification is insufficient attention paid to the func­tional disorders of the dentognathic apparatus.

K.A. Kalamkarov’s classification (1972) is a clinicopathologic characteristics of occlusion, in which there were used the suggestions of E. Angle (1889), N.I. Agapov (1929), G. Korkhaus (1939), A.M. Schwarz (1951), D.A. Kalvelis (1957), V.Y. Kur-liandskyi (1957), L.V. Ilyina-Markosian (1967), and F.Y. Khoroshilkina (1969). The classification (Table 27) takes into consideratioot only the clinical signs of defor­mations, but also the morphologic changes conditioned by the anomalies of teeth and facial bones development.

F.Y. Khoroshilkina (1976) on the basis of teleroentgenologic investigation data singles out dentoalveolar and gnathic peculiarities, macro-, normo-, or micrognathia, anterior, medial, or posterior location of jaws and their inclination relative to the

Table 27. Anomalies of Dentognathic System Development (according to K.A. Kalamkarov)

 

Anomalies of Teeth Development		Anomalies of Jaws Development	Combined Anomalies of Teeth and Jaws
Anomalies of the num­ber of teeth	Adentia Supplemental teeth	Congenital malforma­tions
Anomalies of the posi­tion of teeth	Vestibular, oral, mesial, distal, torsion, high or low position, transposition	Disorders of jaws growth (excessive growth or delay)	Of the whole jaw Of some part
Anomalies of the size and form of teeth		Jaws deformity	Of the whole jaw Of some part
Anomalies of the erup­tion of teeth	Premature eruption Retention	Irregular location of a jaw in the cranium	Anterior Posterior Lateral displacement
Anomalies of the struc­ture of teeth		Derangement of the structure of jaw bones

cranium. According to studied lateral teleroentgenograms of head and characteristic signs the author divides occlusion anomalies into three basic forms: dentoalveolar, gnathic, and mixed. This anomalies classification allows exact indication of pathology localization and choosing an efficient method of treatment.

WHO Classification of Anomalies (1968)

World Health Organization in its diseases systematization offers such dento-gnathic anomalies classification:

1.       Anomalies of jaws sizes:

1.1.Macrognathia of the upper jaw.

1.2.Macrognathia of the lower jaw.

1.3.Macrognathia of both jaws.

1.4.Micrognathia of the upper jaw.

1.5.Micrognathia of the lower jaw.

1.6.Micrognathia of both jaws.

2.       Anomalies of jaws position relative to the cranium base:

2.1.Assymetry.

2.2.Mandibular prognathism.

2.3.Maxillary prognathism.

2.4.Mandibular retrognathism.

2.5.Maxillary retrognathism.

3.       Anomalies of dental arches correlation:

3.1.Posterior occlusion.

3.2.Mesial occlusion.

3.3.Excessive overbite.

3.4.Excessive covering occlusion.

3.5.Open bite.

3.6.Cross bite of lateral teeth.

3.7.Lingual occlusion of lower lateral teeth.

4.       Anomalies of teeth position:
4.1. Density.

4.2.Transfer.

4.3.Torsion.

4.4.Spaces between teeth.

4.5.Transposition.

L.S. Persin’s classification (1989) is morphologic, based on the classification of D.A. Kalvelis and WHO.

L.S. Persin’s classification

1.       Anomalies of dental arches occlusion.

1.1.    Lateral area.

1.1.1. Sagittal:

—posterior occlusion;

—mesial occlusion.

1.1.2. Vertical:

—      dysocclusion.

1.1.3. Transversal:

—cross bite;

—vestibular occlusion;

—palatine occlusion;

—lingual occlusion.

1.2.    Frontal part.

1.2.1. Sagittal:

—sagittal incisive disocclusion;

—reverse incisive occlusion;

—reverse incisive disocclusion.

1.2.2. Vertical:

—      vertical incisive disocclusion;

—straight incisive occlusion;
– deep overbite;

—deep incisive disocclusion.

1.2.3. Transversal:

—transversal incisive occlusion;

—transversal incisive disocclusion.

2.       Anomalies of the occlusion of opposing teeth pairs:

2.1.Sagittal.

2.2.Vertical.

2.3.Transversal.

According to the British Standards of Rendering Dental Service (Oxford, 1998), the clinical practice often uses the classification of canine teeth correlation, because canine teeth position also serves a checkpoint of orthodontic treatment:

•    the 1^st class — the upper permanent canine tooth is in the interdental space
between the lower permanent canine tooth and the 1^st premolar;

•    the 2^nd class — the upper permanent canine tooth is in the interdental space
between the lower canine tooth and the lateral incisor;

•    the 3^rd class — the upper permanent canine tooth is in the interdental space
between the 1^st and 2^nd premolars of the lower jaw.

Now there is not a single classification, which would satisfy all orthodontists in full measure. In Ukraine the most widely used are the classifications of E. Angle, A.I. Betelman, D.A. Kalvelis, and L.P. Grigoryeva. Lately, in connection with the realization of Bologna declaration positions in the system of higher medical educa¬tion, there has been offered to turn to the ICD-10 (International Classification of Diseases). In the Protocols of Rendering Dental Service issued by the MPH of Ukraine and the CMC of higher medical education in 2005 nosologic units and their forms are offered in accordance with several classifications — of E. Angle, A.I. Betelman, D.A. Kalvelis, WHO, and ICD-10.

In everyday practice orthodontists face a number of dentognathic anomalies, when it is impossible to diagnose the disease by existing classifications.

With the purpose of orthodontics study unification in higher educational estab¬lishments and managing orthodontic diseases we offer to word the diagnosis in the following way:

– morphologic part (occlusion anomalies in three planes, dental arches anoma¬lies, individual teeth anomalies) — detecting according to the adapted ICD-10 and finding the class by Angle;

—      etiologic part;

—      functional part;

—      esthetic part.